SAGES and EAES recommendations for surgical response to COVID-19

COVID-19 - The joint statement states that the virus has demonstrated a propensity to spread at an exponential rate in several countries, significantly impacting many lives and affecting our practice as healthcare professionals

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) has released recommendations based on best available evidence and expert opinion from the global surgical community that will help to protect patients, their surgeons and staff from COVID-19.

The joint statement states that the virus has demonstrated a propensity to spread at an exponential rate in several countries, significantly impacting many lives and affecting our practice as healthcare professionals. The statement recommends that:

Surgery

All elective surgical and endoscopic cases should be postponed at the current time, although these decisions should be made locally, based on COVID-19 burden and in the context of medical, logistical and organisational considerations. There are different levels of urgency related to patient needs, and judgment is required to discern between them. The surgical care of patients should be limited to those whose needs are imminently life threatening such as those will malignancy that could progress or with active symptoms that require urgent care. All other surgery should be delayed until after the peak of the pandemic, thereby minimising the risk to both, patient and health care team, as well as the utilisation of necessary resources, such as beds, ventilators, and personal protective equipment (PPE).

All non-essential hospital or office staff should be allowed to stay home and telework.

Adherence to hand washing, antiseptic foaming, and appropriate use of PPE should be strictly enforced. When necessary, in-person surgical consultation should be performed by decision makers only.

All non-urgent in-person clinic/office visits should be cancelled or postponed, unless needed to triage active symptoms or manage wound care.

Where possible, all patient visits should be handled remotely when possible, and in person only when absolutely necessary.

Multidisciplinary team (MDT) meetings should be held virtually as possible and/or limited to core team members only, including surgeon, pathologist, Clinical Nurse Specialist, radiologist, oncologist and coordinator. The MDT is responsible for the decision making and classifying the patient’s priority level of need for surgery.

Procedural considerations

There is very little evidence regarding the relative risks of Minimally Invasive Surgery (MIS) versus the conventional open approach, specific to COVID-19. The societies will continue to monitor emerging evidence and support novel research to address these issues.

They strongly recommended that consideration be given to the possibility of viral contamination to staff during surgery either open, laparoscopic or robotic and that protective measures are strictly employed for OR staff safety and to maintain a functioning workforce.

Although previous research has shown that laparoscopy can lead to aerosolisation of blood borne viruses, there is no evidence to indicate that this effect is seen with COVID-19, nor that it would be isolated to MIS procedures. Nevertheless, for MIS procedures, use of devices to filter released CO2 for aerosolized particles should be strongly considered.

Proven benefits of MIS of reduced length of stay and complications should be strongly considered in these patients, in addition to the potential for ultrafiltration of the majority or all aerosolised particles. Filtration of aerosolised particles may be more difficult during open surgery.

There may be enhanced risk of viral exposure to proceduralists/ endoscopists from endoscopy and airway procedures. When these procedures are necessary, strict use of PPE should be considered for the whole team.

Practical measures

Consent discussion with patients must cover the risk of COVID-19 exposure and the potential consequences.

If readily available and practical, surgical patients should be tested pre-operatively for COVID-19.

If needed and possible, intubation and extubation should take place within a negative pressure room.

Operating rooms for presumed, suspected or confirmed COVID-19 positive patients should be appropriately filtered and ventilated and if possible, should be different than rooms used for other emergent surgical patients. Negative pressure rooms should be considered, if available.

Only those considered essential staff should be participating in the surgical case and unless there is an emergency, there should be no exchange of room staff.

All members of the OR staff should use PPE.

Electrosurgery units should be set to the lowest possible settings for the desired effect and the use of monopolar electrosurgery, ultrasonic dissectors and advanced bipolar devices should be minimized, as these can lead to particle aerosolisation. If available, monopolar diathermy pencils with attached smoke evacuators should be used.

Surgical equipment used during procedures with COVID-19 positive or Persons Under Investigation (PUI) /suspected COVID patients should be cleaned separately from other surgical equipment.

Laparoscopy

Incisions for ports should be as small as possible to allow for the passage of ports but not allow for leakage around ports.

CO2 insufflation pressure should be kept to a minimum and an ultra-filtration (smoke evacuation system or filtration) should be used, if available.

All pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction or conversion to open.

The ability to control aerosolised virus during endoscopic procedures is lacking, so all members in the endoscopy suite or operating room should wear appropriate PPE, including gowns and face shields. Placement and Removal of PPE should be done according to CDC guidelines.

Since patients can present with gastrointestinal manifestations of COVID-19, all emergent endoscopic procedures performed in the current environment should be considered as high risk.

Since the virus has been found in multiple cells in the gastrointestinal tract and all fluids including saliva, enteric contents, stool and blood, surgical energy should be minimised.

Endoscopic procedures that require additional insufflation of CO2 or room air by additional sources should be avoided until we have better knowledge about the aerosolization properties of the virus. This would include many of the endoscopic mucosal resection (EMR) and endoluminal procedures.

Removal of caps on endoscopes could release fluid and/or air and should be avoided.

Endoscopic equipment used during procedures with COVID-19 positive or PUI patients should be cleaned separately from other endoscopic equipment.

Filtration

Filtration may be an effective means of protection from the release of the virus during minimally invasive surgery (MIS) and endoscopy. Masks such as N95 respirators are designed to filter out 95% of particles that are 0.3 microns and larger. Powered Air Purifying Respirators (PAPR) may be beneficial for intubation, extubation, bronchoscopy, endoscopy, and possibly tracheostomy. Intraoperatively, filters are used to remove smoke and particulate matter including viruses. High-Efficiency Particulate Air (HEPA) filters have a minimum 99.97% efficiency rating for removing particles greater than or equal to 0.3 microns in diameter4. Ultra-Low Particulate Air (ULPA) filters can remove from a minimum of 99.999% of airborne particles with a minimum particle penetration size of 0.05 microns5. The Association of periOperative Registered Nurses (AORN) guidelines define ULPA as filters capable of removing particles of 0.1 microns. Filtration is also essential on a larger scale in the positive pressure operative suites. HEPA filters that are placed in the ceiling provide a terminal cleaning. Clean rooms are favored over HEPA filters placed in the ductwork.

Currently, the best practice for mitigating possible infectious transmission during open, laparoscopic and endoscopic procedures is to use a multi-faceted approach, which includes proper room filtration and ventilation, appropriate PPE, and smoke evacuation devices with a suction and filtration system, as available.

Use of filtration during laparoscopy

All pneumoperitonuem should be safely evacuated from the port attached to the filtration device before closure, trocar removal, specimen extraction or conversion to open.

Once placed, ports should not be vented if possible. If movement of the insufflating port is required, the port should be closed prior to disconnecting the tubing and the new port should be closed until the insufflator tubing is connected. The insufflator should be “on” before the new port valve is opened to prevent gas from back-flowing into the insufflator.

During desufflation, all escaping CO2 gas and smoke should be captured with an ultra-filtration system and desufflation mode should be used on your insufflator if available.

If the insufflator being used does not have a desufflation feature, be sure to close the valve on the working port that is being used for insufflation before the flow of CO2 on the insufflator is turned off (even if there is an in-line filter in the tubing). Without taking this precaution contaminated intra-abdominal CO2 can be pushed into the insufflator when the intraabdominal pressure is higher than the pressure within the insufflator.

The patient should be flat and the least dependent port should be utilized for desufflation.

Specimens should be removed once all the CO2 gas and smoke is evacuated.

Surgical drains should be utilized only if absolutely necessary.

Suture closure devices that allow for leakage of insufflation should be avoided. The fascia should be closed after desufflation.

Hand-assisted surgery can lead to significant leakage of insufflated CO2 and smoke from ports and should be avoided. If used to remove larger specimens and protect the wound, it can be placed after desufflation. The specimen can then be removed and the closure performed.

Current wall suction devices do not use ultrafiltration.

The following will help manage surgical patients during the COVID-19 pandemic. These are not formal guidelines and due to time constraints, SAGES has not reviewed them by utilising its standard rigorous guidelines process:

Reusing an N95 mask or making one

There is no definitive “best practice” for N95 re-use and re-processing, so based on the resources available at each institution, the optimal strategy for each person or institution will vary.

The Personal protective equipment (PPE) shortages during the COVID-19 pandemic have precipitated a wave of creative solutions for repurposing of N95 masks. A growing influx of new information can make it difficult to discern best practices for mask re-use. Below SAGES/EAES provide resources and tips on this topic.

Note that based on manufacturer recommendations, N95 masks are designed for one-time use. 3M, a prominent producer of N95 masks, performed internal testing of various sterilizing strategies and does not endorse any of them. However, in times of scarcity, the strategies below are options that can be considered based on individual clinical judgment and the institutional resources available.

What are my options for extending the life of my N95 mask?

It is important to differentiate between extended use, re-use, and mask re-processing.

Extended use

The CDC reports that prolonged N95 mask use can be safe for up to 8 hours and encourages each user to review each manufacturer’s recommendations prior to following this strategy.

Re-use

The number of times a mask can safely be re-used depends on multiple factors, including whether the user was exposed to aerosolizing procedures, how it was stored and whether the mask was soiled. Assuming there is no soiling and minimal to no viral contamination to the outside of the mask, the CDC suggests that masks can be hung to dry or stored in a breathable container in between uses. The following strategy has been suggested by multiple organizations based on the fact that coronaviruses lose their viability significantly after 72 hours - when planning to reuse a N-95 mask, removal of the mask should be done strictly avoiding contamination of the inside of the mask during placement or removal (see below methods for donning and doffing).

Mask Rotation

This method involves acquiring a set number of N95 masks (the American College of Surgeons recommends up to 7) and rotating their use each day, allowing them to dry for long enough that the virus is no longer viable. According to Dr Peter Tsai, the inventor of the filtration media contained in the N95, “Polypropylene in N95 masks is hydrophobic and contains zero moisture. COVID-19 needs a host to survive–it can survive on a metal surface for up to 48 hours, on plastic for 72 hours, and on cardboard for 24 hours. When the respirator is dry in 3-4 days, the virus will not have survived.”

Reprocessing/Decontamination

Mask decontamination strategies range from at-home manoeuvres (not endorsed by the CDC), to mass decontamination in an industrial facility. General principles of re-processing include:

The method must sufficiently inactivate the viral load on the mask.

The mask cannot be soiled (bodily fluids, makeup).

The filtration capacity and ionic charge must be preserved as much as possible.

The fit of the mask cannot be compromised.

The most comprehensive resource available for re-processing is currently published online by the N95 Decon group. This is a collaborative venture with members of academia and private sector who came together to review all available data and to perform experiments to test and optimize recommendations for each method. They provide user-friendly fact sheets as well as technical reports for those interested in more in-depth descriptions.

The N96 Decon Group claims no responsibility for the accuracy of their findings and that reproduction of the findings is at the user’s own risk. Please see the full disclaimer athttps://www.n95decon.org/disclaimer

Below is a brief summary of the most commonly reported decontamination methods. Note that there are many versions of N95 masks, with different strap materials and shapes. Thus, one method may work well for one mask type, and not for another.

Heat

For optimal results, a heating protocol should both completely inactivate viral particles on the mask and preserve the filtration efficacy of the mask. Heating of the mask at 70C for 30 minutes has been suggested as a method of decontamination which adequately preserves the filter integrity for re-use. However, it is unclear whether there is a specific humidity required during this process to completely inactivate SARS-COV-2 viral particles. Due to the dearth of specific data on a protocol to achieve both aims, the N95 Decon group does not recommend this method.

UV treatment

Proper UV treatment of N95 masks requires specific dosing protocols and full surface area illumination to ensure proper inactivation of viral particles with minimal mask degradation. Due to the precision required, home UV light use is not recommended. This method of decontamination has been implemented by some hospital systems in the United States.

Hydrogen Peroxide Vaporisation

Hydrogen peroxide vapor (HPV) decontamination has been shown in pilot studies to allow multiple cycles of N95 processing (up to 50 cycles) with acceptable preservation of function. It is now approved by the FDA as a method for N95 decontamination for healthcare personnel during the COVID-19 pandemic. This method of decontamination is actively being implemented by hospital systems across the United States through Battelle.

My hospital is no longer doing fit testing, or no longer carries the mask I was originally fitted for. Do I have options for performing a seal check at home?

The CDC does not consider a user seal check an adequate substitute for a fit test. If you have to wear a new type of N95 mask, a formal fit test is recommended. To ensure that your mask continues to have an adequate seal with repeat uses, the CDC and OSHA recommend performing a user seal check each time the mask is re-used.

Additional Tips

The University of Nebraska has a compilation of PPE protocols available to healthcare personnel that are based on their extensive experience as a National Ebola Training and Education centre. Pleasehereto access the protocols

Additional considerations

Facial hair is an important consideration when it comes to mask fit. The CDC has recommendations for acceptable configurations. For people who still cannot achieve an adequate seal with an N95, half-face masks or powered air purifying respirators (PAPR) are the next options.

There are various online videos with methods of donning and doffing that help to minimize contact to the front of the mask.Hereis a representative example

The societies note that statements and information are updated regularly and subject to change as more data becomes available.